Still unable to make much meaningful sense of LB’s inquest but moments are surfacing. A few here. Again in no order. Toilet moments. The toilets were back from the courtroom, through the cafe towards the exit. A block of three cubicles for women. Despite strategically timed efforts (roughly aiming for the middle of break times) I always seemed to collide with a jury or Sloven staff member. So blinking awkward.There was only one woman advocate across the other seven legal teams so this was less of an issue [sigh]. I kind of went for a ‘make do and definitely don’t mend’ approach with jury members. This involved eyes firmly on the floor and the usual ‘thank you’ type acknowledgements around holding doors firmly parked.

The kids were upset and angry by the various interactional exchanges that occurred in the courtroom. Smirks, hints of excitement and puff and schmuff between various Sloven bods at the front of the courtroom. A ‘screw face’ technique was tried and tested across the two weeks to manage this.

Rosie also stepped up and explained what it was like to experience this behaviour to a senior Sloven staff member. Love her. Hopefully this has been passed to the Sloven senior team/board and will be incorporated into their inquest policy/engagement. Our and other families’ experiences suggest an over emphasis on staff coaching rather than any thought to what it must be like for family/friends in this setting.

Moments involving Dr M, the consultant psychiatrist, and her barrister, AJ, are sadly hard to forget. For so many reasons. Not least the efforts AJ made to work to a script seemingly derived from the various Disney/Pixar films LB both loved and got so upset about. Depicting me, ‘The mother’ [with extended dramatic pause], as a Cruella de vil type character. Skinning puppies for fur coats.

At one point Paul Bowen, QC, asked Dr M who was the best person to know what LB meant when he said something. This generated avoidance strategies reminiscent of childhood banter hanging out in the car outside pubs with my sisters. Coke, crisps and bickering/discussion with a backdrop of the Grease soundtrack. Dr M, not a child, prevaricated and twisted a knife that should have been removed over two years ago.

That is a very general question. It depends what being said and when it is being said, I cannot ask that question. It would have to be more specific.

[Howl]. There was worse to come. Almost luckily via video link as I’m not sure  what I would have done if she was present after this exchange.

Mr F: You heard Winnie Betsva admit that she had failed Connor, SR and the family, is there any matter relating to failures from your part?

Dr M: It was an act of tragedy. In hindsight, we could have made some different decisions but with the information we had at the time and balancing of pros and cons we made right decision at the time.

Mr F: I asked ‘you’ not we.

Dr M: I made the decision at the time with others weighing information we had at the time and no, I don’t believe there was a failure of care from my part.

An act of tragedy? No failure? Can you even begin to imagine? And this woman is a practicing psychiatrist in Cork having given up her licence here. The GMC still investigating her conduct… There is too much too wrong here. And our beautiful, funny, loving boy is dead.

I’m beginning to think about the inquest with a bit of coherence after a shaky week in which Rich and I repeatedly started sentences “I still can’t believe that…” Some mysteries remain and we have a lot of questions still. Like how the fuck can learning disabled people continue to be treated so badly in 2015?? This is probably the first of a few rambling posts reflecting on this stuff.

My mum has post-inquest shingles which is seriously crap. Can you imagine? Someone needs to look urgently at the enormous emotional, physical and financial cost this system imposes on families. NHS Trusts should not be allowed to inflict such damage with their shitty actions and practices. [Have a look at the similarly awful action dished out by Humber NHS Foundation Trust to Sally Mays and her family.]

This week Verita 2 was published. The broader review into what happened to LB, moving beyond what happened in the unit. Slightly controversial really. It details a stream of failures by Sloven in their takeover activity of the Ridgeway Partnership in November 2012 but concludes LB died as an outcome of clinical staff actions rather than failings on the part of commissioner/Sloven managers. Wow. I’ve tried to read the final version twice and can’t get past p30 (the executive summary). It actually makes my eyeballs ache.

Chris Hatton has provided excellent commentary on this review, ‘Verita, a little less than the truth‘, which concludes;

I cannot reconcile in my head the evidence contained in this report and the conclusions it reaches – short of finding video evidence of Katrina Percy stalking the corridors of STATT with a piece of lead piping I doubt that any evidence would have been sufficient to make Verita reach a different conclusion.

George Julian has also documented why she can’t support the conclusions, looking at both process and content. Within moments of publication of Verita 2, ongoing disgruntlement around Verita’s relationship with NHS England and their ‘independence’ appeared on twitter. Just one example here which is pretty astonishing. Ho hum… This leaves an even bigger question mark for us over the independence of ‘independent reviews’ generally. Having read interview transcripts for Verita 1 and listened to evidence across the two weeks of the inquest, it’s hard to reconcile some of the findings (or unfindings) from the original review.

The secret Oxfordshire County Council review also continues to baffles me. Not just because of the secrecy with which it was conducted and circulated to various organisations a week or so before we got sniff of it, but also because it seems to be an exemplar of a non-independent ‘independent’ review. What’s going on here? Pretence? Delusion? Denial? I dunno. Any explanation is chilling.

All this underlines our concern about the newly introduced Independent Patient Safety Investigations Service (IPSIS) which seems to be headed by Mike Durkin of, er, NHS England. Membership of the expert advisory group is beyond depressing. Nothing like embracing a multicultural, diverse society. Nope. Nothing like it. It seems to be another Winterbourne View Joint Improvement/Bubb type endeavour. All talk and crap all action.

There shouldn’t be layers of ‘independence’. As simple as. Until this is recognised, there’s no point in puffery.

Oh, and for those of you wondering why the Mazars death review hasn’t seen the light of day yet (originally due to be published last summer), Sloven have challenged the review methodology. So it’s being independently validated. Another cracking example of the differing power families and NHS bods have. Despite the latter being responsible for death and the ongoing destruction of families.

It also hints at a level of independence rare in NHS related independent reviews. Here’s hoping Mazars will break the mould. Something needs to happen.

With the proviso that the only thing LB was late for was a trip to the Oxford Bus Company on July 4 2013, here is the inquest in photos….

the family room

the evenings

the media

the journey

the waiting

the last day

the relief

A full on few weeks. Writing witness statements for the coroner a hideous task. Reliving everything that happened. Again. He died? While having to discard what we now know [unit records/CQC inspections seared into my brain/eyelids]. So blinking painful. Then a week or so later, receiving Sloven witness statements. Piercingly painful, sometimes enraging reading.

More reading as both big reviews commissioned by NHS England around LB’s death pitched up. The broader Verita review building on their original review which found LB’s death preventable. And the Mazars review into deaths in Sloven’s mental health and learning disability provision since 2011. These have been circulated for ‘factual accuracy checking’ (just drips off my tongue these days) and won’t be published now until after LB’s inquest. Around 500 pages that must be generating agitational agitations at top Sloven towers level. As it fucking should.

Yesterday was the fourth pre-inquest review hearing at Oxford County Hall. My Life My Choice turned up in force. It makes a difference to see family/ friends/campaigners in the public gallery. Sort of counteracting the apparent ease with which LB’s life seemed to be treated in a ‘deleted/trash emptied’ way. Like so many other people. George Julian brilliantly tweeted much of what was discussed on a new dedicated campaign account; LB’s inquest.

It was just incredibly sad. I don’t know. Maybe more so than the previous three meetings (if that’s possible). Earlier hearings involved thrashing out issues around whether or not the inquest should be an Article 2 inquest with a jury. This related to LB’s human rights – something he was always so (rightly) hot on – under the European Convention on Human Rights. How the state has a duty to protect life.

Back in the day, these were important points to us and we were worried Sloven would derail them. Yesterday it was confirmed that LB’s inquest will start on October 5th for up to two weeks. Discussion turned to witnesses, jury bundles, floor plans and photos.

• Is possibly one of the saddest tasks ever
• Truth, justice and accountability fought for in a process with unimaginable physical and emotional impact
• Enormous financial cost
• And so far from guaranteed

Don’t ever tell me this is an inquisitorial process.